Medicaid Use Report

Documents and Forms

Document Name Document Type
SSI Claims System Screen.pdf Other-Internal Screens
Updated PRA and PA language.docx Other-Privacy Act Statement and Pape

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicaid Use Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.268

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internal Screens			SSI Claims System Screen.pdf		Yes	Yes	Fillable Fileable Signable
Other-Privacy Act Statement and Paperwork Reduction Act (revised)			Updated PRA and PA language.docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 99,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 98 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	99,000	39,000	60,000
Annual IC Time Burden (Hours)	62,700	59,700	3,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.